Field Home-Holy Comforter

Based on interview and record review, the facility's Quality Assurance Committee did not develop and implement plans of action to ensure that residents with severe weight loss are identified and appropriate measures put in place to address the weight loss and to prevent recurrences. This has the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

On 11/14/11 in the afternoon, the Director of the Quality Assurance Committee and the Registered Dietitian (RD) were interviewed regarding how the committee identifies issues to be addressed by the committee and how plans of action are developed and implemented to address those issues.

This interview revealed that one of the issues that is routinely (monthly) addressed is significant weight loss. A document entitled " Quality Improvement Report: Weight Assessment Audit " (presented to the surveyor on the afternoon of 11/10/11) was referenced to explain how the committee addresses significant weight changes. This report does not identify the severity of the weight lost for each resident noted on the list. Also, the information presented to the committee does not provide the committee with sufficient details for the committee to determine if a thorough investigation of the weight lost warrants an in-depth investigation, especially if such a loss is noted for the first time.

The surveyor then referred to Resident #181 cited under F325. This resident had lost 9.9 per cent of his body weight in one month (July 2011), which is considered to be severe as opposed to being significant. However, the information presented to the committee for July's weight losses noted, " Significant weight loss related to poor intakes and C-Diff. Multiple supplements in place. " This interview with the Director of QA revealed that she was not aware of the specific amount of weight lost by the resident and what specific measures were put in place to prevent further weight loss.

Additionally, the resident was presented to the QA committee in August 2011, at which time the resident had experienced an additional 9 percent loss. The report presented to the committee noted: "Significant weight loss related to poor intakes and C-Diff. Multiple supplements in place. " This is the same report presented in July2011. The effectiveness of the planned interventions was not addressed.

415.27(c)(1)(3)(v)

Based on record review and interview, the facility did not ensure that each resident who is incontinent of urine was provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible. Specifically: (1) residents who were assessed as having minimal restorative potential did not receive care and services to restore any degree of continence (#9, #166 ) and (2) a resident did not receive care and services to prevent a decline in bladder control.( # 266) This was evident for 3 of 3 residents reviewed for a decline in urinary continence. ( # 9, 166, 266)

This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.

Findings are:

1. Resident # 9 has diagnoses including Dementia -non Alzheimer's type, according to quarterly MDS 3 (assessment of 9/3/11.(OBRA quarterly) Additional OBRA assessments were 5/18/11; quarterly 6/12/11 and quarterly 9/13/11.

The 5/18/11 and 6/12/11 OBRA assessments revealed that this resident had at least 7 incontinent episodes daily and was on a toileting program.

A review of the facility Bladder Continence Assessment revealed that it referred to medical conditions that affect the restorative potential of the resident ;and medication history referring to medications that affect the restorative potential of the resident. This bladder continence assessment includes cognitive status , mobility, bladder control status, fluid intake as well as medical history and medication history. Total scores on bladder continence assessments were: 17 for 5/11/11, 17 for 6/12/11and 15 for 7/25/11. Total score of 15 indicates minimal restorative potential . Voiding pattern (frequency, volume, nighttime or daytime ) was not done for this resident

A review of Comprehensive Care Plans revealed no care plan for restorative potential for bladder incontinence; although the facility assessment identified the resident as having minimal restorative potential for bladder continence..There was no care plan that identified quantifiable, measurable objectives with time frames, or interventions to guide provision of rehabilitation services,

A review of toileting schedules for April 1 - 22 indicated that the resident was toileted upon arising, mid morning, after lunch, mid afternoon, after dinner, at bedtime, during night, A review of toileting schedule for May 2011 (from 5/12- 5/31) indicated no adjustment of toileting schedule and times toileted remained the same as April.

Interview with unit head nurse on 11/14/11 at 11:12AM revealed that the toileting schedule remained until 5/31/11 and since the resident was "always incontinent" she was then put on a "check and change" program. There are no toileting sheets for June, July, and August. When asked, at this time, why toileting was discontinued in June when the resident's total score on bladder incontinence was 15 and still indicative of minimal restorative potential ,the unit RN indicated that she had met with her staff and had concluded that the resident had no restorative potential . There was no available evidence that the reason for the incontinence was investigated or that any effort was made to identify the type of urinary incontinence.

Interview with a C N A ( Certified Nurse Aide) on 11/14/11 at 11:45AM ,who had taken care of the resident in May, 2011 revealed that in April the resident " was able to tell you she had to go to the bathroom, but when she returned on 5/11/11/-6/1/11 it became increasingly difficult to transfer her to the bathroom so she was placed on check and change status ." According to this interview, the times the resident was toileted were never adjusted and there is no documented evidence of the resident's voiding pattern. According to interview with unit RN on 11/14/11 at 11:30AM she was not aware of the resident voiding pattern form at that time.

Review of bladder continence assessment for 5/11/11 and 6/12/11 revealed that the resident continued to have a total score of 17 (still minimal restorative potential)

There is no documented evidence that this resident received care and services to achieve as much urinary continence as possible. This resident who was assessed as having minimal restorative potential for bladder continence on admission (5/11/11); the assessment of 5/18/11 documented a response to trial of toileting program as decreased wetness; had an assessment of 6/12/11 of having frequent episodes of incontinence (7 or more episodes) daily, was completely incontinent by 11/20011.

2. Resident #166 was admitted to the facility on 5/19/11 with a diagnosis of Dementia.

A review of the resident's initial Minimum Data Set (MDS) an assessment tool indicated that:
-on 5/26/11, the resident was frequently incontinent of Bowel and Bladder but had at least 1 episode of continence of Bowel and Bladder in a 7 day period;
-on 8/20/11, the resident's quarterly MDS revealed that the resident is now always incontinent of Bowel and Bladder.

A review of the facility's Bladder Continence Assessment indicated that:
- on 5/19/11, the resident was assessed to have a low restorative potential for bladder incontinence;
- on 8/24/11 the resident was assessed to have a minimal restorative potential for bladder incontinence.

A review of the resident's Care Plan for Activities of Daily Living (ADL) dated 8/24/11 revealed that the resident recieves total care for all ADLs
which includes incontinence care by staff.

In an interview with the resident's day Certified Nurse Assistant (CNA) on 11/9/11 at 1:10PM, she indicated that the resident when taken to the toilet is sometimes found to be continent of Bladder and Bowel. When asked where this information is documented. the CNA stated that she tells the nurse but does not document when the resident has been found to be incontinent of either Bladder and Bowel.

In an interview with resident's evening CNA on 11/9/11 at 3:30PM, he stated that resident is always incontinent of Bowel and Bladder.

In an interview with the Head Nurse, on 11/9/11 at 4:00PM, she stated that the resident is not currently on a toilet schedule. In addition, she was not aware that the resident was sometimes continent of Bowel and Bladder.

3. Resident #226 was admitted to the facility on 5/31/11 for rehabilitation services. The resident, who is wheelchair bound, has diagnoses that include Dementia.

The Bladder Continence Assessment form dated 5/31/11 showed that the resident was frequently incontinent on a daily basis and had a moderate restorative potential (by habit/prompted training).

The ADLs (activities of daily living) tracking sheets done prior to the completion of the initial Minimum Data Set (MDS, an assessment tool) showed that the resident was being toileted and also had briefs changed (due to episodes of incontinence).

The initial MDS dated 6/7/11 showed that the resident was occasionally incontinent of bladder, continent of bowel and requires assistance with toileting.

A review of the resident's Comprehensive Care Plan revealed that no plan of care with measurable goals and interventions was developed to address incontinence based on habit training or any other method. Also, the CNA care guides did not reflect any interventions to toilet the resident.

Another assessment form for incontinence dated 8/19/11 showed that the resident was incontinent of urine, i.e. has no bladder control. A plan of care was developed on that date to address incontinence. However, there was no intervention listed to attempt to improve the resident's level of bladder control.

The quarterly MDS dated 8/26/11 showed that the resident was frequently incontinent as opposed to being incontinent all the times.

The charge nurse (RN) assigned to care for the resident at the time of the quarterly MDS was interviewed on 11/14/11 in the afternoon. She offered no explanation as to why there was a discrepancy between the two assessments completed in August 2011.

The charge nurse (RN) on the unit on which the resident currently resides and the CNA assigned to care for the resident on the day shift were interview also in the afternoon on 11/14/11. The CNA stated that the resident is currently incontinent and is not taken to the toilet. The charged nurse was asked if there was an incontinence care plan for the resident prior to showing a decline in the level of her bladder control in August 2011. The charge nurse stated that the resident recently transferred to her unit and she does not know if there was one.

Later that afternoon the surveyor asked the Director of Nursing (DON) to conduct a search of the resident's record, including the overflow portion, to determine if a plan of care was developed for the resident in June 2011. After conducting a search, the DON stated that none was found.

415.12(d)(2)

Based on record review and interview, the facility did not ensure the accuracy of an MDS 3 (assessment). Specifically an MDS 3 (assessment) indicated that the resident was on a toileting program to manage urinary incontinence , when the toileting program had been discontinued 12 days prior to completion of the MDS. This was evident for 1 of 3 residents reviewed for urinary incontinence. (# 9)

This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.

Findings are:

Resident # 9 has diagnoses including Non Alzheimer's Dementia.

A review of the facility Bladder Continence Assessment of 5/11/11 (date of admission) revealed that this resident had a total score of 17 which is indicative of minimal restorative potential.

A review of the MDS 3 (an assessment) of 6/12/11 for Resident# 9 indicated that the resident was on a toileting program being used to manage urinary incontinence.

Interview with the unit Head Nurse on 11/14/11 at 11:14AM revealed that the toileting program was discontinued after 5/31/11 as the resident was always incontinent. Interview with the Director of Nursing on 11/14/11 at 2:15PM revealed that she was unable to explain why the MDS 3 had been checked for a toileting program in process. Interview with the MDS 3 nurse on 11/14/11 at 2:25PM as to why the MDS 3 was checked indicating that a toileting program was in place when it was discontinued 6/1/11 revealed that she was on vacation and had not returned until 6/14/11. Interview with the MDS 3 nurse, who had been covering for the vacationing MDS 3 nurse, revealed that she was unsure as to whether or not she had done this assessment.

415.11(b)

Based on record review and interview, the facility did not involve each resident in an ongoing program of activities that is designed to appeal to their interests and to enhance the resident's highest practicable level of physical, mental, and psychological well -being. Specifically, Resident #89 has not attended the facility activity programs as they do not appeal to her. This was evident for 1 of 37 sampled residents reviewed.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings are:
Resident #89 is an 84 year old female admitted to the facility on 8/12/11 from the hospital. Her diagnoses include: Morbid Obesity, Osteoarthritis and Diabetes Mellitus.
Review of this resident's medical record on 11/10/11 at 11:00AM, revealed that on the Activity Assessment form, this resident enjoys: music programs, social events, bingo, pet therapy and conversing about topics of interest. There was no evidence of further documentation of this resident's attendance at activity programs, or an updated Care Plan since 8/18/11.
Interview with this resident on 11/10/11 at 1:15PM, regarding her attendance at facility activities, revealed that she attended bingo one time and felt unwanted and thus uncomfortable and did not attend again. Resident #89 further revealed that the activity staff has not spoken with her regarding what activities she would like to attend nor have they encouraged her to attend any activities.
Interview with the facility Activity Director on 11/14/11 at 10:47AM, regarding this resident's attendance at activities, revealed that he has seen her using the computer in the library and that the activity staff visit this resident 2-3 times a week for 10-15minutes. The Activity Director was unable to provide documentation of the activity staff visits to this resident.
415.5(f)(1)
I

Based on interview and record review, the facility did not formulate comprehensive care plans with measurable objectives, timetables and specific interventions:1) to prevent decline in continence for two residents that had occasional incontinence 2) to develop a hospice care plan for a resident receiving Hospice services.This was evident for 3 of 37 residents reviewed. (Residents #9, #184 and # 266).

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Findings are:

1. Resident #226 was admitted to the facility on 5/31/11 for rehabilitation services. The resident, who is wheelchair bound, has diagnoses that include Dementia.

The Bladder Continence Assesment form dated 5/31/11 showed that the resident was frequently incontinent on a daily basis and had a moderate retorative potential (by habit/prompted training).
The ADLs (activities of daily living) tracking sheets done prior to the completion of the initial MDS showed that the resident was being toileted and also had briefs changed (due to episodes of incontinence.

The initial Minimum Data Set (MDS, an assessment tool) dated 7/7/11 showed that the resident was occasionally incontinent of bladder, continent of bowel and requires assistance with toileting.

A review of the resident's Comprehensive Care Plan revealed that no plan of care with measureable goals and interventions was developed to address incontinence after the completion of the MDS (or prior to its completion) as required.

The resident had changed units 3 times during her stay at the facility. Two of the charge nurses (RNs) assigned to the resident were interviewed on 11/14/11 in the afternoon. They were asked to search for an incontinence care plan developed for the resident in June 2011. After they failed to produce one, the surveyor asked the DON to conduct a search for one. The DON searched the resident's record including the overflow portion and stated that none was found.

2. Resident # 9 has diagnoses including Dementia -non Alzheimers type, according to quarterly MDS 3 (assessment of 9/3/11 quarterly) Additional assessments were 5/18/11; quarterly 6/12/11 and quarterly 9/13/11.

The 5/18/11 and 6/12/11 OBRA assessments revealed that this resident had at least 7 incontinent episodes daily and was on a toileting program.

A review of the facility Bladder Continence Assessment revealed that it referred to medical conditions that affect the restorative potential of the resident ;and medication history referring to medications that affect the restorative potential of the resident. This bladder continence assessment includes cognitive status , mobility, bladder control status, fluid intake as well as medical history and medication history.This resident has had BIMS (brief interview mental status) of 3 [9 and below indicative of cognitive impairment] for the 3 MDS3's done. However total scores were : 17 for 5/11/11, 17 for 6/12/11, and 15 for 7/25/11. Total score of 15 indicates minimal restorative potential. Voiding pattern (frequency, volume, nighttime or daytime ) was not done for this resident

A review of Comprehensive Care Plans revealed no care plan for restorative potential for bladder incontinence; although the facility assessment identified the resident as having minimal restorative potential for bladder continence..There was no care plan that identified quantifiable, measurable objectives with time frames, or interventions to guide provision of rehabilitation services,

Interview with the unit Head Nurse on 11/14/11 at 11:12 AM revealed that there was no care plan for restore potential for bladder incontinence as she was of the opinion, after talking to her staff, that the resident did not have a restorative potential of urinary incontinence.

3. Resident # 184 has diagnoses including Lung Cancer.
A review of the medical revealed that the resident was re-admitted to the facility on 8/1/2011 after a hospitalization .

Further review of the record revealed that the resident had a physician's order for a Hospice evaluation dated on 10/17/11 .

Review of the medical record revealed a Hospice intake was done on 10/21/11 and resident started receiving Hospice services .Further review of the record revealed there was no Hospice care plan in the resident's record and there was no Physician's order for Hospice Care.

In an interview with the Licensed Practical Nurse Patient Care Coordinator (PCC) on 11/08/11 at 10:00AM she had no explanation why the resident had no Hospice Care Plan and why there was no Physician's order for Hospice Care.

In an interview with the Hospice Representatives on 11/09/11 at 10:00 AM they concurred that the resident should have had a care plan in the chart at the start of care.

415.11(c)(1)

Based on record review and interview, the facility did not ensure that Comprehensive Care Plans were reviewed and revised to reflect the resident's current status. Specifically, (1) the resident bowel and bladder was not reviewed to assess the resident's current ability for bowel and bladder continence (Resident # 166); (2) an activity care plan was not revised to reflect the resident's current non- participation in activities. This included revised goals, interventions and outcomes for an alert resident, who does not participate in recreational activities. This was evident for 2 of 37 residents in the sample ( Resident #89, 166).

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #166 was admitted to the facility on 5/19/11 with a diagnosis of Dementia.

A review of the resident's initial Minimum Data Set (MDS) an assessment tool indicated that:
-on 5/26/11, the resident was frequently incontinent of Bowel and Bladder but had at least 1 episode continence of Bowel and Bladder in a 7 day period;
-on 8/20/11, the resident's quarterly MDS revealed that the resident is now always incontinent of Bowel and Bladder.

A review of the facility's Bladder Continence Assessment indicated that:
- on 5/19/11, the resident was assessed to have a low restorative potential for bladder incontinence;
- on 8/24/11 the resident was assessed to have a minimal restorative potential for bladder incontinence.

A review of the resident's Care Plan for Activities of Daily Living (ADL) dated 8/24/11 revealed that the resident receives total care for all ADLs
which includes incontinence care by staff.

In an interview with the resident's day Certified Nurse Assistant (CNA) on 11/9/11 at 1:10PM, she indicated that the resident when taken to the toilet is sometimes found to be continent of Bladder and Bowel. When asked where this information is documented. the CNA stated that she tells the nurse but does not document when the resident has been found to be incontinent of either Bladder and Bowel.

In an interview with resident's evening CNA on 11/9/11 at 3:30PM, he stated that the resident is always incontinent of Bowel and Bladder.

In an interview with the Patient Care Coordinator, Resident Nurse, on 11/9/11 at 4:00PM, she stated that the resident is not currently on a toilet schedule. In addition, she was not aware that the resident was sometimes continent of Bowel and Bladder.

The facility did not revise the care plan to reflect the resident's change in bowel and bowel continence.

2. Resident #89 is an 84 year old female admitted to the facility on 8/11. Her diagnoses include: Diabetes Mellitus, Osteoarthritis and Morbid Obesity.
Review of the Care Plan for Activities on 11/10/11 revealed that it was an " interim care plan " dated 8/18/11. There was no documented evidence that this care plan had been revised to reflect the resident's current non-participation in facility activities or a plan to include this resident in individual activities of her choice.
Interview with Resident # 89 on 11/10/11 regarding her participation in facility activities, revealed she attended bingo one time and felt uncomfortable and has not attended any activities since that time and activity staff have not approached her with alternative activities of her choice.
415.11(c)(2)(i-iii)

Based on interview and observation, the facility did not consistently use aseptic technique for a dressing change. Specifically, a resident's wound was potentially contaminated during a dressing change. This was evident for 1 of 3 residents observed for dressing change technique.(Resident # 89).

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Findings are:

Resident # 89 is an 84 year old female admitted to the facility on 8/12/11 with diagnoses that include Stage 4 Pressure Ulcers of the Left heel and Left Posterior aspect of the Lower Extremity, Diabetes Mellitus, and Osteoarthritis.

Observation of this resident's wound care and dressing change on 11/10/11 at 10:45AM, revealed, that after the Wound Care Physician cleaned the two Stage 4 Pressure Ulcers of the Left Lower Extremity, the Registered Nurse (RN) Patient Care Coordinator (PCC), who was assisting the Physician at that time, rested the resident's left leg directly on the bed sheet, potentially contaminating the 2 Stage 4 Pressure Ulcers on the Left Lower Extremity.

In an interview with the RN PCC at that time, regarding placing this resident's cleaned Pressure Ulcers directly on the sheet, she stated that "the Treatment Nurse will put a clean dressing on it when she gets to it". After Surveryor intervention, the RN PCC placed a sterile drape under the 2 Stage 4 Pressure Ulcers until the Treatment Nurse could apply an aeseptic dressing to the Pressure Ulcers.

415.19(a)(1-3)

based on observation and interview resident #89 had breeches in infection control during dressing change on 11/10/11 at 10:45am...nurse was unaware that she contaminated resident,s wounds x 2...she placed heel with stg 4 pu directly on the sheet... and when holding the left leg she held directly on the posterior wound and stated that she was unaware....

Based on observation, record review and interview the facility failed to ensure that the resident area remained free of accident hazards as evidenced by 1) a resident with history of multiple falls was observed walking in the hallway with a rolling walker without supervision 2)call bells not being observed within the reach of residents able to use them. This was evident of 4 of 37 residents.( Residents #1, 194, 327, 334)

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Findings are :

Resident # 194 was admitted on 6/10/11 with diagnosis including Parkinsons Disease

During an observation on 11/10/11 the Resident was observed walking back and forth in the hallway of 3B. Resident was ambulating with a rolling walker and there was no staff in the vicinity .Resident was observed from 11:30AM until 12 noon without any staff in the area .

Review of the Resident 's medical record revealed that on the Interdisciplinary Care Plan for Fall Risk there was documentation indicating 11 falls since the time of Admission with interventions for each occurrence.

Further review of the medical record revealed that the Resident's Falls Potential Assessment indicated that Resident's current Fall Risk done on 11/1/11 after the last fall was a score of 28 (any score above 14 = High Risk Fall Prevention Program)

Review of the Resident Care Guide (tool used for the Ceritfied Nursing Assisstant )CNA stated 150 ft of ambulation with the rolling walker and close supervision.

Review of the Physical Therapy documentation revealed the Resident is to utilize rolling walker with supervision.

Review of the most recent Minimum Data Set (MDS) dated 9/13/11 for Functional Status revealed the Resident requires the assist of one for all areas.

In an interview with a CNA on 11/11/11 on the day shift ,assigned to the Resident stated the resident should have the resident close to them while ambulating in case the Resident "loses his balance".

In an interview with the Licensed Practical Nurse, (LPN)Patient Care Coordinator (PCC) on 11/11/11 at 10:30 AM she stated when the Resident is out of his room she usually walks with him .She had no explanation of why the previous day the Resident was observed walking without any staff supervision.

2. a)On 11/7/11 at 12:15PM, Resident #334, who is wheelchair bound, was observed seated in her wheelchair alone in her room while receiving oxygen via a concentrator. The resident's call bell was place on her bed and was not accessible to her.

b)Observation on 11/7/11 in the PM hours revealed Resident #327 seated in her wheelchair near her bed. At that time, the resident's call bell was clipped next to the wall directly adjacent to the head of the resident's bed.

c)Obsevation on 11/8/11 at 10:04AM revealed Resident #1 in bed with the head of her bed elevated. The resident's call bell was behind her bed on the floor and not accessible to the resident. This situation was immediately brought to the attention of a Licensed Practical Nurse on the unit who then entered the room and placed the call bell in Resident #1's reach while stating that the bell should not hae been where it was first observed.

415.5(f)(1)

Based on observation, interview and record review, the facility did not ensure that supplemental fluids provided at meal times and between meals to a resident at risk for dehydration were monitored for acceptance. This was evident for 1 of 1 residents reviewed for dehydration(#291).

This has the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident #291 was admitted to the facility on 7/21/11. The resident's diagnoses include Cerebral Vascular Accident (a stroke).

The resident's Comprehensive Care Plan (CCP) reflected the goal: "Resident will not experience dehydration." The interventions to achieve this goal included monitoring fluids. The evaluation section of the CCP dated 9/21/11 stated that the resident is encouraged to consume fluids secondary to poor intake. The evaluation also noted that the resident needs 2590 cc daily and consumes 960 - 1500 cc. A dietary note also written on 9/21/11 stated that the resident is provided 1200 cc daily via supplements and that the resident's intake will continued to be monitored. The note did not address the resident's acceptance of this drink.

An interview with the dietitian on 11/9/11 at 2:35 PM to clarify when the supplements were offered revealed that the resident is provided a liquid commercial supplement with meals and a can of ginger ale in the afternoon..

On 11/10/11 at 12:30 PM the resident was observed during meal time. There was no supplemental fluid offered to the resident. The surveyor then reviewed the resident's meal ticket, which reflected a selective menu. One of the items on the ticket was Boost Breeze Drink. The cook/server then informed the surveyor that the drink was not circled on the selective menu and was therefore not provided. He also stated that sometimes the resident does not drink the Boost. The dietitian was then interviewed and stated that the number sign (#) is printed next to the drink to inform staff that it is to be served to the resident even if the resident did not choose that item.

A review of the Food/Fluid Consumption Sheets showed that the resident's fluid intake was in the range of 600 - 1440 cc at meal times daily for October 2012 and 840 - 1320 cc for November 2012. These sheets did not indicate when the resident was served the Boost Breeze Drink and/or how much of it was actually consumed. The ginger ale offered in the afternoon was listed on the nourishment sheet. However, there was documentation to indicate if it was offered and how much was consumed.

415.12(j)

Based on interview and record review, the facility did not ensure that the physician was notified promptly of a change in a resident's medical condition that warranted physician's interventions. This resulted in delay of treatment to address frequent loose stools indicative of an infectious process. This was evident for one sampled resident ( Resident # 181) and has the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident #181 was admitted to the facility for rehabilitation services. The resident's diagnoses include Dementia, Hypertension and Anemia.

A review of documentation for daily bowel movements revealed that the resident began to experience loose stools as noted on the CNA ADL Signature Sheet as follows:

7/08/11 - 3 episodes
7/09/11 - 3 episodes
7/10/11 - 3 episodes
7/12/11 - 2 episodes
7/13/11 - 3 episodes
7/14/11 - 3 episodes

On 7/9/11 the nursing staff reported to the physician that the resident's white blood count was elevated. There is no documented evidence that the physician was notified of the frequent loose stools at that time. The physician ordered chest x-rays and complete metabolic panel (C MP) CBC (blood count), chest x-ray and urine analysis.

There is no documented evidence until 7/13/11 to indicate that the physician was notified of the presence and/or frequency of the loose stools. At that time the physician ordered an anti-diarrhea medication and on 7/14/11 gave an order to obtain stool specimen to rule out an infection. The resident tested positive for C-difficile, bacteria that cause diarrhea.

On 7/10/11 in the afternoon, the Director of Nursing (DON) was interviewed about the care of the resident, who was discharged on in September 2011. The DON stated that the night shift is assigned to review the bowel movement records and should have reported the frequency of the loose stools so that it could have been addressed promptly by the physician.

415.3 (e)(2)(ii)(c)

Based on interviews and record review, the facility did not ensure that a resident was provided the necessary care to prevent significant unplanned weight loss. Specifically:

1. The nursing staff did not promptly notify a medical personnel regarding a change in the resident's medical condition that had the potential of causing significant weight loss;
2. The resident's weight was not monitored in accordance with standard of practice for nutrition for early identification of changes;
3. The efficacy of dietary supplements was not determined prior to providing them to the resident to prevent unplanned weight loss, and;
4. The resident's acceptance of planned dietary supplements was not monitored when initiated.

This was evident for 1 of 4 residents reviewed for nutritional concerns (Resident #181). This has the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident #181 was admitted to the facility on 7/04/11 for rehabilitation services. The resident's diagnoses include Dementia, Hypertension and Anemia.

The initial comprehensive assessment or Minimum Data Set dated 7/11/1 revealed that the resident's admission weight was 143 pounds.

A review of the Food and Fluid Consumption record revealed that the resident's intake at meal times during the first two weeks of admission (7/5/11 - 7/19/11) varied from refusal to 100 percent (with refusals to 50 per cent at 30 of the 45 meals provided.

During this period of time the resident began to experience loose stools as noted on the CNA ADL Signature Sheet as follows:

7/08/11 - 3 episodes (one of the episodes noted to be very large)
7/09/11 - 3 episodes
7/10/11 - 3 episodes
7/12/11 - 2 episodes
7/13/11 - 3 episodes (with one of the episodes noted to be very large)
7/14/11 - 3 episodes
7/15/11 - 1 episode
7/17/11 - 1 episode
7/18/11 - 1 episode
7/19/11 - 3 episodes

There is no documented evidence that the loose stools (23 episodes) were acknowledged by the nursing staff until 7/12/11 as reflected in a note on the 24 Hour Nursing Report for that day. However, it was not until 7/13/11 that there is any documented evidence to indicate that the physician was notified of the presence and/or frequency of the loose stools. At that time the physician ordered an anti-diarrhea medication and on 7/14/11 gave an order to obtain stool specimen to rule out an infection.

A review of the resident's weight chart revealed that the resident was not weighed until 7/20/11 at which time his weight was noted to be 130 pounds. This represents a loss of 13 pounds or 9 per cent in 2 weeks.

According to a dietary note dated 7/20/11, the dietitian acknowledged resident's weight loss on that date. Two of the probable causes the dietitian attributed to the weight loss were varied appetite and loose bowel movements.

The planned dietary interventions to address this loss were Ensure (one can), a commercial dietary supplement, and ice cream (per the resident's preference). There is no documented evidence that the resident's actual caloric intake was determined and used as a basis for determining the amount of Ensure to provide the resident.

On 8/5/11 the dietitian documented that the resident weighed 129 pounds, Ensure continued and that the resident will be encouraged to consume it. This note did not indicate if the resident was accepting the Ensure and ice cream. There is no documented evidence that the supplements were offered and how much was consumed.

On 8/13/11 the dietitian documented that the resident's weight had declined to 118 pounds, a loss of 11 pounds in one week. She noted at this time that the resident will be offered Ensure Plus with meals and between meals to prevent further weight loss. There is no documented evidence that the Ensure was provided with meals. (On 9/7/11 the resident's weight was noted to be 118.6 pounds.)

The dietitian (who is not registered) assigned to the resident was interviewed on 11/10/11 in the afternoon. The dietitian was asked why the resident was not weighed weekly. She stated that it is the facility's policy to weigh a resident twice during the first month following admission and monthly there after. When asked what was the determining factor for choosing one can of Ensure for the resident, she stated that she usually starts with one can first as opposed to comparing the resident's actual intake to his daily requirement as indicated by nutritional standards of practice. The dietitian was also asked if she knew how much of the Ensure was actually consumed by the resident. She was not able to state how much.

On 11/14/11 in the afternoon, the Registered Dietitian was interviewed. She stated that the facility used to have residents weighed weekly for the first month following admission. The policy was changed to weigh residents weekly for the first 2 weeks. She, however, stated that because of the resident's clinical condition (poor appetite and loose stools) he should have been weighed weekly.

415.12(i)(1)

Based on observation and interview the facility did not ensure that posted staffing contained all of the required information. Specifically the posted staffing did not include the actual hours worked by licensed and unlicensed staff directly responsible for resident care per shift. This was evident for 12 licensed and 24 unlicensed staff providing care for residents on the day shift of 11/7/11.

This resulted in no actual harm with potential for minimal harm that is not immediate jeopardy.

Findings are:

Observation of posted staffing for day shift , on 11/7/11 at 9:02AM, revealed that actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift had not been included in the posting. The total number of staff directly responsible for resident care on the day shift 11/7/11 was posted, but not the actual hours worked.

Interview with the Director of Nursing (DON) on 11/7/11 at 11:30 AM revealed that the DON had not been aware that the actual hours worked by staff directly responsible for resident care were required to be posted.

NFPA 101 (2000 edition) Chapter 2 states:

The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code.

NFPA 101 (2000 edition) 2.1.2 includes ASME/ANSI A17.3-1993 Safety Code for Existing Elevators and Escalators, including Addendum A17.3a-1994 and A17.3b-1995.

ASME A17.3 (1993) 3.11.3 states:

Elevators shall conform to the requirements of ASME/ANSI A17.1-1987 Rules 211.3 through 211.8 (Appendix C).

ASME A17.1-1987 (Appendix C) Rule 211.3b states:

Smoke detectors shall be installed in each elevator lobby at each floor. The activation of a smoke detector in any elevator lobby, other than at the designated level, shall cause all cars in all groups that serve the lobby to return nonstop to the designated level. If the smoke detector at the designated level is activated, the cars shall return to an alternate level approved by the enforcing authority.

This Requirement is not met as evidenced by:

Based on observation and interview the existing elevators do not conform to the ASME/ANSI A17.3-1993 Safety Code for Existing Elevators and Escalators in that the facility's elevators have the potential of stopping at a fire floor. Specifically, the elevators are not programmed to return to an alternate floor if a smoke detector at the designated floor, i.e. main level, is activated. Additionally, once stopped at the potential fire floor the elevator doors are programmed to remain in the open position.

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Findings are:

On 11/09/11 at 11:10AM, during a test of the fire alarm system it was observed that the elevators
(3 of 3) were recalled to the main level where they remained in the " open " position. When asked if the elevators would bypass the main level if it was the " fire floor " and stop on an alternate level, the Director of Plant Operations stated that they would not, and that the elevators always stop at the main level and that the doors always remain in the open position.

In an interview on 11/09/11 at 10:30AM the Director of Plant Operations stated that he would contact the elevator company to discuss the above findings.

NFPA 101 (2000 edition) 2.1.1
ASME A17.3-1993 Rule 3.11.3
ASME A17.1- 1987 Rule 211.3b
Uniform Fire Code (NFPA 1) 2003 edition 11.3.1.2
10NYCRR 711.2